A nurse employed at a nursing home is caring for a client who has recently
been transferred from the hospital to the nursing home. The client is
... [Show More] confused
and is acting out. The nurse suspects the client is suffering from relocation
stress. The nurse should include which helpful actions in the plan of care?
Select all that apply.
A. Encourage friends and family to visit frequently. Correct
B. Establish a trusting relationship with the client as soon as possible.
Correct
C. Change rooms frequently to prevent the client from becoming
bored.
D. Ensure the client is an active part of decision making regarding
their care. Correct
E. Allow the client to move around the halls as desired to decrease the
confusion and acting-out.
Rationale: Relocation stress can occur when a client is removed from their
usual surrounding such as home. In order to provide safe and quality care,
encourage friends and family to visit the client often and establish a trusting
relationship with the client as soon as possible. It is important for the client to
have an active role in decision-making. In order to lessen confusion, the nurse
should provide the client time to become familiar with the immediate
surroundings such as his or her room before allowing or encouraging
ambulation to new surroundings; allowing the client to move around the halls as
desired may increase confusion and acting-out behaviors. Likewise, changing
the client’s room frequently may increase confusion.
Test-Taking Strategy: Focus on the subject, relocation stress. Also note that
the client is confused and acting-out. Think about this type of stress and the
manifestations and what you might expect from a client who is experiencing
relocation stress. Use that knowledge to determine appropriate nursing actions.
Review: relocation stress.
Level of Cognitive Ability: Creating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process: Planning
Content Area: Fundamentals of Care: Safety
Priority Concepts: Safety, Stress
HESI Concepts: Safety, Stress and Coping
References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical
nursing: Patient-centered collaborative care. (7th
ed. p. 19). St. Louis, MO: W.B. Saunders Company.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., p. 70). St.
Louis: Mosby.
Awarded 2.0 points out of 3.0 possible points.
10.ID: 9477034772
The nurse is caring for a client in the hospital and is reconciling the client’s
home medications. The client is taking Lactobacillus,
a probiotic over-the counter medication. The nurse is discussing the supplement
with the client. What statement by the client would warrant the need for further
teaching? Select all that apply.
A. “I can take my probiotic at any time of day or night.” Correct
B. “Probiotics can be found in yogurt and some juices.”
C. “I should take this supplement to prevent gas and bloating.” Correct
D. “Because I’m lactose intolerant, a probiotic would not benefit me.”
Correct
E. “This supplement will help me avoid getting diarrhea from
antibiotics.” Incorrect
Rationale: Probiotics are live microorganisms that are similar to those found
naturally occurring in the gastrointestinal tract. Probiotics should be taken as
directed, usually with a meal, and can have a side effect of gas and bloating. If
gas an bloating do occur, the client should be advised to try a different type of
probiotic. Probiotics are recommended for those clients who are lactose
intolerant. Probiotics are found in foods such as yogurts and some juices and
can be helpful to treat antibiotic-associated diarrhea.
Test-Taking Strategy: Note the strategic words, need for further teaching.
These words indicate a negative event query and the need to select he
incorrect client statements. Use knowledge of probiotic supplements to
determine the correct options. Review: the uses and effects of probiotics
Level of Cognitive Ability: Evaluating
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Pharmacology: Gastrointestinal Medications
Priority Concepts: Client Education, Health Promotion
HESI Concepts: Health Promotion, Teaching and Learning/Patient Education
References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical
nursing: Patient-centered collaborative care. (7th
ed. p. 10). St. Louis, MO: W.B. Saunders Company.
Rosenjack Burchum, Rosenthal (2016), pp. 1325-1326.
Awarded 1.0 points out of 3.0 possible points.
11.ID: 9477042148
The nurse educator is presenting a lecture on child neglect. Which statement by
one of the students indicates that the teaching has been effective? Select all
that apply.
A. “A sign of neglect are bruises on the child’s body.” Correct
B. “Neglected children show aggression after age 10.”
C. “Neglect is parental failure to meet a child’s basic needs.” Correct
D. “Neglected children often have learning problems and low selfesteem.” Correct
E. “Neglect occurs when a parent does not seek medical attention for
a sick child.” Correct
Rationale: Neglect has serious consequences for children. Basically, there are
5 types of child neglect: physical neglect; psychological or emotional neglect;
medical neglect; mental health neglect; and educational neglect. One sign of
physical neglect is bruising on the child’s body. Neglect is the parental failure to
meet a child’s basic needs such as: food, shelter, comfort, love, and medical
attention. Consequences of neglect include: learning problems, low self-esteem,
developmental delays, passivity and juvenile delinquency. Children who are
neglected often show signs of aggression before the age of 2.
Test-Taking Strategy: Focus on the strategic word “effective”. Determine which
statements indicate that the teaching has been effective, by determining which
statements are true. Note the age of the child in option 2. This will assist in
eliminating this option. Review: Signs of child abuse.
Level of Cognitive Ability: Evaluating
Client Needs: Psychosocial Integrity
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Giddens Concepts: Health Care Law, Interpersonal Violence
HESI Concepts: Health Policy/Systems – Health Care Law, Violence
References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p.
353). St. Louis: Mosby.
Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and
children (10th ed. p. 562). St Louis: Mosby.
Awarded 3.0 points out of 4.0 possible points.
12.ID: 9477032667
The nurse is obtaining the medical history from an older client with a black eye
and bruising to the head. The nurse suspects that the client has been abused,
and that there may be a history of abuse. Which statement by the client
indicates the need for further questioning by a social worker? Select all that
apply.
A. “Perhaps I somehow did this to myself.” Correct
B. “I tripped over a rug and now I have a black eye.” Correct
C. “I got into a car accident yesterday and the airbag deployed.”
D. “Well, I don’t remember anything that would have caused the
injuries.” Correct
E. “Sometimes my grandson becomes angry with me when I can’t
give him money.” Correct
Rationale: There are certain elements in the medical history that raise concern
for physical abuse. Perpetrators may provide a history of events that are
incomplete or inconsistent with injuries seen. Many individuals who experience
interpersonal violence are unable or afraid to provide an accurate account of
events. Often individuals will provide a history of trauma that is inconsistent with
the physical examination. It is unlikely that these injuries were self-inflicted or
the result of tripping over a rug. Having no recollection of how an injury occurred
should be an alert to the nurse, as well as statements that another person
caused the injury. The nurse should immediately report this to a health care
provider and the social worker so that proper intervention and follow-up can be
arranged. A car accident with air bag deployment could reasonably cause the
injuries to the client. The nurse should continue on with assessment, treatment
and arrange follow-up care for the client.
Test-Taking Strategy: Focus on the subject, “abuse to an older client”.
Determine which statements made by the client would indicate that abuse may
be occurring. Abuse individuals often make statements that do not correlate with
injuries. Eliminate option 3, because air bag deployment could have caused the
client’s injuries. Review: Signs of abuse in the older client.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Leadership/Management
Giddens Concepts: Clinical Judgment, Interpersonal Violence
HESI Concepts: Health Policy/Systems – Health Care Law, Violence
References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p.
354.). St. Louis: Mosby.
Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and
children (10th ed. pp. 565-566). St Louis: Mosby.
Awarded 3.0 points out of 4.0 possible points.
13.ID: 9477043128
The nurse is meeting with an older client who was brought into the health care
facility for evaluation. According to the family member, the client has lost a large
amount of weight recently and does not eat much. Which actions would be the
most important for the nurse to take? Select all that apply.
A. Assess the client's eyesight. Correct
B. Question the client about urinary habits.
C. Obtain a list of the client's medications. Correct
D. Determine the fit of the client's dentures. Correct
E. Assess the client for mental status changes. Correct
Rationale: Older adults in the community or in any health care setting are most
at risk for poor nutrition. The nurse should review the medical history to
determine the possibility of increased metabolic needs or nutritional losses,
chronic disease, trauma, recent surgery of the gastrointestinal tract, drug and
alcohol abuse, and recent significant weight loss. Each of these conditions can
contribute to malnutrition. As part of a thorough assessment, the nurse should
assess the client's eyesight. Clients with poor vision are often not able to drive
to obtain groceries or cook for themselves. The nurse should also obtain a list of
the client's medications, both prescription and over-the-counter. Certain
medications can alter the taste perception and decrease the desire to eat. It is
also important for the nurse to determine the fit of the client's dentures. Poor
fitting dentures can lead to painful sores, which lead to a decrease in food
intake. The nurse should also include an assessment of the client's mental
status, observing for behavoir that may be abnormal for the client. Utilizing the
family member's knowledge of the client's typical behavior will be important in
the treatment of this client. While the client's urinary status is important to
assess, it is not the most important action for the nurse to take at this time
because it is not directly related to weight loss.
Test-Taking Strategy: Focus on the strategic words, “most important”. Next,
determine which actions would help the nurse determine the cause of the
client’s weight loss. Eliminate option 2, because questioning the client’s urinary
habits would not be directly related to determining the cause of weight loss.
Review: Older Adult Nutrition.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity.
Integrated Process: Nursing Process/Implementation.
Content Area: Nutrition
Giddens Concepts: Clinical Judgment,
Nutrition
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Metabolism -
Nutrition
Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 1341). Philadelphia: Saunders.
Awarded 3.0 points out of 4.0 possible points.
14.ID: 9477042181
The nurse is caring for a malnourished client with dementia and a history of
rheumatoid arthritis, and is creating a plan of care for the client’s nutrition.
Which nursing actions are most appropriate for increasing the client's caloric
intake? Select all that apply.
A. Provide pain medications as needed. Correct
B. Play soft, calming music during mealtimes. Correct
C. Serve the food at the appropriate temperature. Correct
D. Provide the client with six small meals per day. Correct
E. Encourage the client to eat quickly, to prevent fatigue.
Rationale: Malnutrition results from inadequate nutrient intake, increased
nutrient losses, and increased nutrient requirements. Inadequate nutrient intake
can be linked to poverty, lack of education, substance abuse, decreased
appetite, and a decline in functional ability to eat independently, particularly in
older adults. In order to support the client, the nurse should provide pain
medication as needed so that the client is comfortable during meal times. The
nurse can make mealtime positive by providing a quiet environment, which is
conducive to eating. Soft music may calm those with advanced dementia or
delirium. It is important that the nurse serve the client’s food at the appropriate
temperature, in order to make the food appealing to the client. Arranging for the
client to eat six small meals per day, instead of three large meals, may increase
the client’s desire to eat, and prevent the client from being overwhelmed by a
large amount of food at each meal. It is important that the nurse avoid rushing
the client through a meal, but allow as much time as needed.
Resource: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 1340, 1343). Philadelphia:
Saunders.
Test-Taking Strategy: Focus on the strategic words, “most appropriate.”
Eliminate option 5, because this action would likely cause the client to take in
fewer calories. Review: Malnutrition.
Level of Cognitive Ability: Creating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Nutrition
Giddens Concepts: Health Promotion,
Nutrition
HESI Concepts:Health, Wellness, and Illness – Health Promotion, Metabolism
- Nutrition
Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 1340, 1343). Philadelphia:
Saunders.
Awarded 3.0 points out of 4.0 possible points.
15.ID: 9477036624
The nurse is educating a client on obesity. Which statements by the client
indicate a need for further teaching? Select all that apply.
A. "Type II diabetes is a complication of obesity".
B. "I will likely develop obstructive sleep apnea".
C. "Physical inactivity is one of the causes of obesity".
D. "My heart and lungs are mildly affected by obesity". Correct
E. "It is unlikely that I will develop peripheral artery disease". Correct
Rationale: Obesity refers to an excess amount of body fat when compared with
lean body mass. After receiving education from the nurse, the client should be
able to state that complications and risks of obesity such as type II diabetes and
peripheral artery disease and other cardiovascular and respiratory system
complications such as obstructive sleep apnea. It is also important that the
nurse discuss the causes of obesity, which include physical inactivity.
Encouraging the client to exercise 20 minutes per day can decrease the risk of
obesity and life threatening illnesses.
Test-Taking Strategy: Focus on the strategic words, “need for further
teaching.” Think about the physiological effects of obesity to assist in answering
correctly. Eliminate statements that show that the teaching has been effective,
such as options 1, 2, and 3. These options demonstrate that the client has an
adequate understanding of the consequences of obesity. Options 4 and 5 are
incorrect, showing the client would benefit from further education from the
nurse. Review: Obesity.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Nutrition
Giddens Concepts: Client Education, Nutrition,
HESI Concepts: Health, Wellness, and Illness: Nutrition/ Teaching and
Learning:Patient Education
Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 1350). Philadelphia: Saunders.
Awarded 2.0 points out of 2.0 possible points.
16.ID: 9477038260
The nurse is attending a teaching sessionatt on communicating with the ill child.
Which statement by the nurse indicates that the teaching has been effective?
Select all that apply.
A. "I will strive to maintain honesty and trust with each child". Correct
B. "Children are often reluctant to ask questions, when they fear the
answers". Correct
C. "Providing as much information as possible will help ease the
child's fears". Incorrect
D. "Complete honesty may cause problems for some family and staff
members". Correct
E. "To prevent misunderstandings, I should ask the child to explain
what is known". Correct
Rationale: Communication is the most important factor in establishing a good
relationship with the child and family. The nurse caring for the ill child should
strive to make the child feel comfortable, as well as decrease any fears that the
child may have. After listening to the lecture on communication with the ill child,
the nurse should understand the need to strive to maintain honesty and trust
with each child. Lack of honesty and trust can hinder care and leave the child
feeling frightened. The nurse should also understand that children often are
reluctant to ask questions when they fear the answers. The nurse should keep
the child informed, while clarifying any questions the child has. Clarifying
questions can help the nurse avoid providing more information than the child
wants or can handle emotionally. Providing too much information may be
overwhelming and frightening to the child. It may also inhibit future questions
and interaction with the nurse. It is important for the nurse to consider that not
everyone agrees with complete honesty; at times, parents may directly ask the
nurse to withhold information from the child. It is important that the nurse
maintain honesty, using terms that the parents agree upon. One of the most
important aspects of communicating with a child is to have the child explain
what is already known to them about their illness. The nurse can then answer
questions accordingly without overwhelming the child with information.
Test-Taking Strategy: Focus on the strategic word, “effective.” Think about the
developmental process and the effects illness can cause Determine which
statements show that the nurse has an understanding of the topic,
communication with the ill child. Eliminate option 3, because this statement
indicates that more education is needed. Review: Communication techniques. [Show Less]